Finding a better way to treat opioid addiction

They come to Segue Clinic in crisis, their reasons as complex as addiction itself.

Some are desperate to kick oxycontin, others are in a fentanyl spiral.

Dr. Fraser MacKay has seen the variations. He knows not all follow the same path.

“There are different communities of people that we treat,” said MacKay on a tour of his James Street Segue Clinic in St. Catharines — one of a number of such outpatient centres in Niagara and Hamilton specializing in opioid addiction.

Some users have been taking the drugs addictively for a short period. Here, stabilization and weaning off the opioids is key.

Others, who have abused for a longer time, may also be managing chronic pain.

A “harm-reduction” group may have stubborn addiction issues alongside chronic mental health and poverty-related problems.

“It’s that group, that is typically on a program for much longer, that everyone takes about,” said MacKay, a Segue partner. “They don’t see the other groups who’ve been in ... six months or two years, are successfully weaned off opioids, and move on with their lives.”

Patients coming to his clinics are carefully screened and cared for by a group of community partners and counsellors, that include Quest Community Health Care’s urgent service access team.

“You need to have an integrated approach to have the best outcomes,” MacKay says. The overarching goal is to “facilitate stabilization, abstinence and recovery” in a process that typically includes multiple-step programs and therapy.

It’s also true that not all patients are safe or appropriate candidates for methadone-maintenance programs to kick opioids, MacKay said.

Those diverted from such treatments can include youth, people with medical issues and those cross-addicted to alcohol or other substances and who could overdose.

“You have to tailor it to the individual,” he says. And that that can include an often better-tolerated Suboxone, which is considered safer and far less likely to cause an overdose.

“You really have to be so cautious with … methadone to be sure they don’t put themselves in harm’s way,” said the longtime St. Catharines addiction medicine doctor.

“It’s the reason why there’s so much monitoring in place,” he said of a process much like chronic disease management in a “non-judgmental” medical relationship.

Meanwhile, the number of patients on methadone has shot up in in Ontario alone from 3,000 in 1996 to almost 51,000 — almost four times the per-capita rate in the U.S.

The Ontario Health Ministry now pays $156 million a year to support the program, with total physician fee-for-service billings for methadone patients $117.5 million for 2014/15.

Some of that also flows to the Niagara Health System.

Linda Boich, NHS vice president of mental health and addictions, said methadone clinics are offered at three of its sites, “providing care to clients who have an opiate addiction with methadone or Suboxone replacement therapy. “

“Treatment is offered by a therapeutic team, including physicians who specialize in addiction as well as addiction counselling staff,” she said.

In the last fiscal year, 435 patients were cared for at the NHS methadone clinics.

Health minister Dr. Eric Hoskins says recent research has highlighted alternatives to methadone that may provide better support for people with opioid addictions. Other other jurisdictions – notably Vancouver Coastal Health – have adopted new approaches.

“Much of the evidence is pointing to an increased role for Suboxone, which is less addictive, less prone to abuse, less likely to cause a fatal overdose and can be taken at home,” Hoskins said, in an e-mail response to The Standard.

“This would help ensure that this care can be embedded within primary care so that patients being treated for opioid issues can be treated for all of their care needs holistically,” he said, adding supports should also include community mental health, “which we know produces better outcomes for patients.”

Ontario’s Liberal government is concerned enough about growing methadone usage that Hoskins set up a methadone task force late last year to put forward a program to better serves patients’ needs.

In his e-mail, Hoskins said for many, access to methadone and the supports with it can be a life-saver and access to treatment is vital.

MacKay supports this review.

“The issues that have been brought forward are great questions,” he said, at the end of his clinic interview. “We do need to be reassessing our programs and looking at how to get best outcomes.